How is the CPAP type determined for Medicare participants?

[Janknitz]

The "30-day window" is what major mask manufacturers give to DME's to allow them to trade out masks that don't work for patients for whatever reason. The DME can return the mask to the manufacturer and they get a replacement for the next patient at no charge. Then the DME can give you another mask to try. It's a win win for the manufacturers, since once you settle on a mask you are going to be a repeat customer, and it's no risk for the DME. The DME get paid for a mask (remember, all the masks are the same HCPC's billing code, so it doesn't matter a bit to the insurer whether you end up with an LT or an FX or any other mask).

You are doing something different in that you don't want to pay for ANY mask from this DME. It's a wash for the DME, in that they could still get a replacement from the manufacturer, but they will be out your insurance payment if you return this mask, so they see it as a loss (even though it really isn't). They will have to spend time and money to reverse the billing, and they aren't going to like that.

You are going to have to put the screws to this DME. Call your insurer, explain the situation (emphasizing that the DME failed to provide you with the mask your doctor ordered) and see if they have any advice in dealing with the DME to reverse the billing. If the DME gives you trouble, work up the ladder to the on site manager and beyond. Make it clear that they can't meet your needs which is why you are going elsewhere.

Good luck--it may be worth it to either stick with the LT until you're due for a replacement, or pay for your own mask with the DME (if the new DME is really nice, they may give you a free sample FX and save you a LOT of trouble!).

[tigeragent]

The "30-day window" is what major mask manufacturers give to DME's to allow them to trade out masks that don't work for patients for whatever reason. The DME can return the mask to the manufacturer and they get a replacement for the next patient at no charge. Then the DME can give you another mask to try. It's a win win for the manufacturers, since once you settle on a mask you are going to be a repeat customer, and it's no risk for the DME. The DME get paid for a mask (remember, all the masks are the same HCPC's billing code, so it doesn't matter a bit to the insurer whether you end up with an LT or an FX or any other mask).

You are doing something different in that you don't want to pay for ANY mask from this DME. It's a wash for the DME, in that they could still get a replacement from the manufacturer, but they will be out your insurance payment if you return this mask, so they see it as a loss (even though it really isn't). They will have to spend time and money to reverse the billing, and they aren't going to like that.

You are going to have to put the screws to this DME. Call your insurer, explain the situation (emphasizing that the DME failed to provide you with the mask your doctor ordered) and see if they have any advice in dealing with the DME to reverse the billing. If the DME gives you trouble, work up the ladder to the on site manager and beyond. Make it clear that they can't meet your needs which is why you are going elsewhere.

Good luck--it may be worth it to either stick with the LT until you're due for a replacement, or pay for your own mask with the DME (if the new DME is really nice, they may give you a free sample FX and save you a LOT of trouble!).

I spoke with the insurance and they told me as you indicated....they cover the mask by billing code. They said to try to return the mask, and if the DME provider will not accept it, to document this and when the old DME provider files a claim, to submit an appeal describing the situation. If the insurance agrees with me they will deny the claim (however if this happens I assume that they will come after me to pay the entire amount). Its a hassle for me, but I don't want to reward poor service by letting them give me the wrong mask, and ask me to pay for it as well!

[freshair]

My sleep clinic uses the PR system one remstar c-flex and after the study they recommended the [2] DME to go see that had the same machine and mask as the clinic had--My DME told me that this machine was fairly new and just came out last August 2009--My thinking is that you need to ask your family doctor or primary physician who they reccomend for sleep testing and follow their advice--I be super happy with my sleep dr and dme--FA

[XSnorer]

One more piece to add to the mix. When purchasing a new system, some insurance providers will allow the DME's to submit line items claims that detail the xPAP machine, machine filters, hose, mask, mask strap, mask cushions. Some will not. Instead they treat the claim as a bundle. (Not sure what Medicare does since I don't have this.) A line item detail typically provides more $ to the DME so they prefer this method. All costs submitted by the DME are at the highest levels to insure they max out against what the provider will pay. My recent upgrade had a total submitted cost of $6000.

Once the DME finds out the max the insurer will pay, they then go through the game that janknitz described above. They want to make the most profit they can. They alreay know how much they will receive from the insurance provider. So the only other number they can work with is the cost of the machine provided. So they sometimes tend to promote "bricks" as janknitz called it.

When I approached my DME and told them I wanted the S9 they first told me to find that I would need to find another DME? I said why? Their response was something that equated to not making enough money on the transaction. I probed further. I quickly found out the DME rep had a $ figure in mind that my provider would pay. I had already called my insurance provider so I knew the numbers. I knew the DME's guess was less than half of what my insurance provider would pay. I knew the insurance numbers would be higher because my provider allows line item detailing of each piece of the bundle as described above.

So I told them to submit a pre-check type claim and find out the amount they would receive. If they liked the result then we can follow-thru with the claim. If not OK, then I'd find a new DME do business with. (They had been my DME for the last 5.5 years and I've been happy with them.. I knew that they were going to be OK. I realized that the person on the phone had made an erroneous assumption.) Anyway, the results came back and they were very pleased with my coverage. I could tell from the dialogue that they most likely made more $ from my S9 claim than they did from what the other insurance providers paid them for their lesser machines.

[tigeragent]

You are going to have to put the screws to this DME. Call your insurer, explain the situation (emphasizing that the DME failed to provide you with the mask your doctor ordered) and see if they have any advice in dealing with the DME to reverse the billing. If the DME gives you trouble, work up the ladder to the on site manager and beyond. Make it clear that they can't meet your needs which is why you are going elsewhere.

Good luck--it may be worth it to either stick with the LT until you're due for a replacement, or pay for your own mask with the DME (if the new DME is really nice, they may give you a free sample FX and save you a LOT of trouble!).

To end this story, I went to the old DME provider (Lincare) to turn in my S9 Escape. Since I knew they weren''t going to refund me the mask, I wanted to get a full face mask that I might want to use down the road. I inquired about the 30 day return policy on the masks and this is their response ---- "Since you turned in your machine today, we no longer have a patient/client relationship with you. We do honor the 30 day return policy, and would exchange it for another mask if you continued to rent the machine, but we only do this for our current patients." I tried to reason with them that purchasing supplies such as masks does not have to be with the same DME as the machine provider per my insurance, but they didn't care.

They let me keep the Resmed carry bag though....woo hoo!!

I marched right over to the new DME provider (Sleepmed), told them this story, and they are giving me a new Swift FX for free, since they know insurance won't cover a 2nd mask. I happily thanked them for my new S9 Autoset.

[Emilia]

Woot!! Congrats on your new machine and mask.... the new DME knows how to treat a new customer!! I hope all future transactions with them are as pleasant. Happy sleeping and sweet dreams!

[Janknitz]

Way to go, Tiger. That's GRRRRRRRREAT!!!!!!!!!!!!!!!!!! (Sorry, couldn't help myself!).

When I approached my DME and told them I wanted the S9 they first told me to find that I would need to find another DME? I said why? Their response was something that equated to not making enough money on the transaction. I probed further. I quickly found out the DME rep had a $ figure in mind that my provider would pay. I had already called my insurance provider so I knew the numbers. I knew the DME's guess was less than half of what my insurance provider would pay. I knew the insurance numbers would be higher because my provider allows line item detailing of each piece of the bundle as described above.

XSnorer, I have to say that your DME is refreshing for their honesty, and I can see why you stuck with them. This is WAY better than all those lying DME's (hmmm, rhymes with SOB's!) who try to pretend things like "your insurance won't cover that" or "your prescritpion doesn't call for that" or "you have to pay us more if you want that"[FRAUD!]. And the other important piece here is that YOU did your homework beforehand and knew the facts so that you could partner with the DME to make it a win/win situation for both of you. Good going!

The only sad part of your story, XSnorer, is that this came off like a used car deal instead of a necessity of life health care provision. But again, at least they were open and honest with you--most DME's would not be.

[XSnorer]

The only sad part of your story, XSnorer, is that this came off like a used car deal instead of a necessity of life health care provision. But again, at least they were open and honest with you--most DME's would not be.

You are right. Kinda sad. But i still had my "old car" so luckily urgency was a factor with me.

As you know, one has to lookout for #1. There are 4 sides involved (in my case anyway): the ME (#1), the ENT, the DME, the insurance provider. It helps when all 4 on the same page in the playbook. It's easy to see from this forum that too frequently that does not happen. Most of the time when it doesn't happen, it seems to be because "#1" doesn't know or has not been told, or has not researched to find out what the "rules" are. Once you know the rules you can generally get the best solution possible. E.g. in my case, I found out from my insurance provider there was only one xPAP code and that it did cover APAP. The DME provided the code for the APAP. But, one of the DME reps originally told me that a new sleep study would be required. They were wrong. I then had my ENT write AUTO on the script. This made it a requirement. Then knowing my insurance coverage & knowing the DME cost, gave me the needed info to complete my "used car" deal. All went according to plan, mostly because time was on my side.

It's very tough to hit optimal the first time out. I can easily understand why many get fooled on their first try. They are somewhat handicapped because urgency is not in their favor. However, I find it difficult to understand why some get burned in try #2. Hopefully this forum can help provide a bit of help to all who are in this "game", whether it's their original purchase, or second, or third....

But you are right. It's kinda sad that it sometimes goes down as a "used car deal".

[BlackSpinner]

As you know, one has to lookout for #1. There are 4 sides involved (in my case anyway): the ME (#1), the ENT, the DME, the insurance provider. It helps when all 4 on the same page in the playbook. It's easy to see from this forum that too frequently that does not happen. Most of the time when it doesn't happen, it seems to be because "#1" doesn't know or has not been told, or has not researched to find out what the "rules" are. Once you know the rules you can generally get the best solution possible.

But you are right. It's kinda sad that it sometimes goes down as a "used car deal".

The problem for most people is that like me when I first went to my DME I was so tired and brain dead that even the information on this board was too confusing to understand. I tried to do the right thing and research but it was just soooo weird and mind boggling that I just accepted the machine and price. I was lucky and got a data capable machine and with in a week I was able to understand what there was on this board. Other people were not so lucky, plus the whole thing cost me twice as much as it should have (No insurance).

[Janknitz]

I think that people are blindsided when they start out on this journey because they expect their doctor (and by extension the sleep lab) and the DME to be working for them to provide optimal care. That's how it SHOULD be, but that's not how it IS.

Each has their own profit-minded agenda that has nothing to do with #1, the newly diagnosed individual. It seems to be the very rare physician or DME who cares at all about the patient. In some sleep lab scenarios, the "sleep specialist" never even meets the patient and certainly doesn't want to spend uncompensated time holding the patient's hand with equipment "trivialities", the patient's primary care physician is clueless about SA other than generalities and totally clueless about masks and machines, and the DME is all about maximizing profit. Sleep medicine and DME's are all about business and profit, the patient is very far down on the list of prioritiees.